TG100 Flashcards
where do many of the failures in radiation oncology occur?
errors in workflow and process
what is TG100?
application of risk analysis methods to radiation therapy quality management
FMEA
failure modes and effects analysis
issue with work practises in individual clinics
very variable
not like linacs where there are some standard designs and you can prescribe QA
-have to analyze processes and develop clinic and site specific quality management programs that affect work practises in individual clinics
techniques used in TG100
process mapping
FMEA
fault tree analysis
3 things included in TG100
(1) the rationale for prospective risk analysis; (2) how to perform process- and clinic-specific risk analysis and quality management program formulation; and (3) a detailed sample application of the method applied to a generic IMRT process
does TG100 recommend making sudden big changes to workflow after the analysis?
No, discuss with experts and team first
make sure still compliant with regulations
4 recommendations of TG100
- Don’t make sudden large changes to workflow due to results of analysis
- Start with a small project
- Use redundancy
- Quality department at the clinic can likely provide help
what happens to physics resource demands as methods become more intensive and complex?
the demand grows
-ex IMRT and OBI QA
What is linked to serious errors in some radiation therapy accidents?
mental and physical overload
what is not meeting the desired level of quality?
failure
definition of quality
Those features which meet the needs of the patient,including rational medical, psychological, and eco-nomic goals while also taking into account the profes-sional and economic needs of the caregivers and theinstitution.
•A clinical process that is designed to realize cancer treat-ments that conform with nationally accepted standardsof practice and specifications; and
•Freedom from errors and mistakes
define error
failures consisting of acts, either of commission(doing something that should not have been done)or omission (not doing something that should have been done), that incorrectly execute the intended action required by the process
define mistakes
failures due to incorrect intentions or plans, such that even if executed as intended would not achieve the goal
define violations
failures due to intentionally not followingproper procedures, either as shortcuts with the intentionof achieving the correct goal or sabotage
define event
the entire scenario, including the failure it-self and its propagation through the clinical pro-cess, resulting in a patient treatment of diminished quality
define near-event
a situation resulting from a failure that would have compromised quality of the patient’s treat-ment had it not been detected and corrected. Also known as close call, near miss, and good catch
types of failures
human
equipment
organizational or design (latent)
what is essential performance
defined by the International Electrotechnical Commission (IEC) as the performance neces-sary to achieve freedom from unacceptable risk
risk mangement
systematic application of management policies, procedures, and practices to the tasks of analyzing,evaluating, and controlling risk
risk assessment
considers the way in which the quality of treatments can fail to achieve the desired goals
4 components of quality management
quality planning
quality control
quality assurance
quality improvement
difference between QC and QA
QC maintains integrity of process
QA provides confidence that the output of the process is correct
i.e. QC is about input and QA about outpout
for example, QC failure would be not realizing a system is using the wrong calculation algorithm. QA failure would be not seeing that the calculated result is incorrect
QC usually requires more resources than QA
RCA
root cause analysis
reactive approach to safety (once an incident occured or almost occurred)
-focuses on systems and processes rather than individual blame